Basic Information
| Provider Information | |||||||||
| NPI: | 1790717957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | SAURABH | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 332 S JUNIPER ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920254941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602916621 | ||||||||
| FaxNumber: | 7607373430 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 E 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920254212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662282236 | ||||||||
| FaxNumber: | 7607373430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | A62633 | CA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 30835651205 | UT | N | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | CB258485 | 01 | CA | MEDICARE PTAN | OTHER |